Basic Information
| Provider Information | |||||||||
| NPI: | 1396926317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EASTABROOKS | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5076 | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440615076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402098590 | ||||||||
| FaxNumber: | 4402098590 | ||||||||
| Practice Location | |||||||||
| Address1: | 9485 MENTOR AVE STE 210 | ||||||||
| Address2: | PRIMEHEALTH | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440608723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402055833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 09/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP-09641 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2797853 | 05 | OH | MEDICAID | P00626775 | 01 | OH | MEDICARE RAILROAD PIN | OTHER |